ETApplicant
Address:
Telephon(
Application #155n05� I ail—
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harneft.org/permits
Application for Existing Septic Tank In a Mobile Home Park
Property Owner:
Lot Address:
r.
1,953 -2e) 2
Name of Park: 11h Lic- (Lot Number: /,to
ParcelA'6(63 a � PIN: 0(t 52- � L", - 064)
v/SW —DW TW (Size # Bedrooms 3 Year 20 I'S
Power Company: (For Progress Energy we need the premise number.)
Specific Directions to Job from LilliagLo-n:
r
There is a $100.00 charge for this service. This certification is subject to revocation If the
Intended use of the septic system changes, or It false Information Is provided on this
application.
You signature below certifies,that alt,qbove information is
Signature of owner o(�authorizedl ageh I t:'5)/V/��
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
of Environmental Health Specialist Date
SEPTIC 4/08